Minerva anestesiologica
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Minerva anestesiologica · Mar 2012
ReviewAcute respiratory distress syndrome: evaluation and management.
Acute respiratory distress syndrome (ARDS) is a life-threatening condition that affects patients admitted in the Intensive Care Units (ICUs) under mechanical ventilation. ARDS is a process of non-hydrostatic pulmonary edema and hypoxemia associated with a variety of conditions, resulting in a direct (e.g., pneumonia) or indirect (e.g., sepsis) lung injury and is associated with a significant morbidity and mortality. ⋯ In the last decades, the recognition that mechanical ventilation can contribute to harming the lung has changed the goals of this therapy and has driven research to focus in ventilatory strategies that mitigate lung injury. This review emphasizes clinical aspects in the evaluation and management of ARDS in the ICUs and updates the latest advances in these therapies.
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Prothrombin complex concentrates (PCCs) are purified drug products with hemostatic activity derived from a plasma pool. Today, PCCs contain a given and proportional amount of four non-activated vitamin K-dependent coagulation factors (II, VII, IX, and X), a variable amount of anticoagulant proteins (proteins C and S, and in some antithrombin) and low-dose heparin. In some countries PCC products contained only three clotting factors, II, IX, and X. ⋯ They may be considered as safe preparations if they are used for their approved indications at the recommended dosage with adequate precautions for administration, and have been shown to be effective for reversing the effect of VKAs. Their adequate use based on decision algorithms in the perioperative setting allows a rapid normalization of International Normalized Ratio (INR) for performing emergency surgery, minimizing bleeding risk. This review aims to propose two algorithms for the use of PCCs in the perioperative setting, one to calculate the PCCs dose to be administered in a bleeding patient and/or immediately before urgent surgery, based on patient's clinical status, prior INR and INR target and another for reversing the action of oral anticoagulants depending on urgency of surgery.
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Analgesics and sedatives are commonly prescribed in the ICU environment for patient comfort, however, recent studies have shown that these medications can themselves lead to adverse patient outcomes. Interventions that facilitate a total dose reduction in analgesic and sedative medications e.g. the use of nurse controlled protocol guided sedation, the combination of spontaneous awakening and breathing trials, and the use of short acting medications, are associated with improved outcomes such as decreased time of mechanical ventilation and ICU length of stay. This purpose of this review is to provide an overview of the pharmacology of commonly prescribed analgesics and sedatives, and to discuss the evidence regarding best prescribing practices of these medications, to facilitate early liberation from mechanical ventilation and to promote animation in critically ill patients.
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Both malnutrition and the physical injury related to trauma and surgery increase the expression of T-helper 2 (Th2) lymphocytes which cause impaired cell mediated immunity. Activation of the hypothalamic-pituitary-adrenal axis and sympathoadrenal system with the release of cortisol and catecholamines drive the development of Th2 cells. Th2 cytokines result in the accumulation of arginase-1 expressing myeloid-derived suppressor cells in lymphoid tissue. ⋯ Prostaglandin-E2 released following trauma plays a synergetic role with cortisol and catecholamines in driving these pathways. There is now increasing evidence that immunomodulating enteral formulas supplemented with arginine and omega-3 fatty acids can reverse many of the immune mediated changes and decrease the number of adverse outcomes after major surgery and trauma. These immunomodulating enteral formulas should be strongly considered in surgical patients undergoing major surgery and following severe trauma.